SSA-9000 - Old Version

Social Security Administration

Important Information

Local FO

Return Address

Date:

CLAIMANT NAME

ADDRESS

CITY ST ZIP

The Social Security Administration is committed to communicating with you effectively. We have a process to help you, as a blind or visually impaired person, to request an accommodation that will help us communicate with you.

Requests We Automatically Approve

For blind or visually impaired persons, we automatically approve requests for notices in standard print by first class or certified mail, in Braille, or on Microsoft Word compact discs. We also approve requests for standard print by first-class mail followed by a telephone call from us. To request one of these formats, you can:

• Visit our website at www.socialsecurity.gov/notices and follow the steps provided;

• Call us toll-free at 1-877-708-1776; or

• Write or visit your local Social Security office.

Other Requests for Accommodation

To request a different accommodation (such as large print or audio compact disc), you can:

• Call us toll-free at 1-800-772-1213; or

• Call or visit your local Social Security office; or

• Fill out the enclosed “Request for Accommodation” form and send it to: Social Security Administration, P.O. Box 17794, Baltimore, MD 21235-7794. You can also write to this address about an accommodation request you have already made.

When we decide whether or not to approve your request, we will mail you our decision as well as the reasons we came to that decision.

If You Have Any Questions

For general information about Social Security, we invite you to visit our website at www.socialsecurity.gov on the Internet. For general questions and specific questions about your case, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 123-45-6789. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY/TDD number at 1-800-325-0778. If you do call or visit an office, please have this letter with you. It will help us answer your questions.

Signature of FO manager

Enclosure: SSA-9000 Request for Accommodation

Form Approved

Social Security Administration OMB No 0960-XXXX

Request for Accommodation

REQUESTOR INFORMATION
1A. NAME		1B. DATE OF REQUEST
1C. ADDRESS
1D. SOCIAL SECURITY NUMBER	1E. PHONE NUMBER (including area code)
ADDITIONAL INFORMATION
2. CONDITION THAT CAUSES YOU TO REQUEST AN ACCOMMODATION
3. ACCOMMODATION REQUESTED Please list the accommodation that would enable you to participate fully.
4. EXPLANATION Briefly describe why each of our currently offered accommodations (standard print by first class or certified mail, Braille, Microsoft Word file, and a telephone call), is not adequate for you:

Privacy Act Notice for Request for Accommodation

The Rehabilitation Act of 1973 (as amended), 29 U.S.C. §§ 701 et seq., and Section 205(a) of the Social Security Act (as amended), 42 U.S.C. § 405(a), authorize us to collect this information. The information is needed to verify your identity and to process your request for a notice accommodation. Providing this information is voluntary. However, failure to provide all or part of the requested information may prevent the Social Security Administration from processing your request.

We rarely use the information you supply for any purpose other than for verifying identity and processing your notice accommodation request. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to: (1) to enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage; (2) to comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veteran Affairs); (3) to make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and (4) to facilitate statistical research, audit or investigative activities necessary to assure the integrity of Social Security programs.

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, state or local government agencies. Information from these matching programs can be used to establish or verify a person’s eligibility for Federally funded and administered benefit programs and for repayment of payments or delinquent debts under these programs.

Our notices, additional information regarding this application, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995.  You do not need to answer these questions unless we display a valid Office of Management and Budget control number.  We estimate that it will take about 20 minutes to read the instructions, gather the facts, and answer the questions.  You may send comments on our time estimate above to:  SSA, 6401 Security Blvd, Baltimore, MD  21235-6401.  Send only comments relating to our time estimate to this address, not the completed form.

Form SSA-9000-F4 (XX-2010) DRAFT 5